Red alert on TB infection control in clinics

– Results of TAC survey of 207 public clinics shows TB infection control still falling short. – Government must urgently conduct an infection control audit of all public facilities

JOHANNESBURG, 19th MARCH 2018 – In the run up to World Tuberculosis (TB) Day on 24 March 2018, the Treatment Action Campaign (TAC) assessed the state of TB infection control in a number of clinics across South Africa. Of 207 facilities assessed, 145 were found to be in a “RED” state with very poor infection control measures in place.

In March 2017, TAC produced our first annual TB audit. Last year, 72% of the facilities (115 out of 158) were ranked “RED” compared to 71% (145 out of 207) this year. 9% of facilities (15 out of 158) scored “GREEN” last year, compared to a dismal 1% this year (2 out of 207).

TB remains the leading reported cause of death in South Africa with over 33 063 deaths (8.4% of natural deaths) in the country in 2015[1]. Based on the latest data in 2016, the rate of new cases of active TB in South Africa remains extremely high at around 438 000[2]. While total TB rates do appear to be slowly declining (down from 250 000 in 2015), multi-drug resistant TB (MDR-TB) and extreme drug resistant TB (XDR-TB) rates are increasing. The World Health Organization (WHO) estimated 19 000 cases in South Africa in 2016 up from 7 350 in 2007[3]. TB can be spread through the air when people with active TB disease cough or sneeze. However, various infection control measures can be taken to reduce the risk of TB transmission.

“Our clinics should be places we feel safe, where we know we can get decent healthcare services. They certainly should not be places we can get TB. The reality is that many clinics aren’t even doing the basics to prevent us getting TB as we wait to see a nurse. They are overcrowded. People are not screened for TB. Often staff don’t even offer a tissue to someone coughing,” says Sibongile Tshabalala, TAC National Chairperson.

TAC branches in Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo, Mpumalanga, and Western Cape engaged in the audit during TB month, March 2018. The following questions were answered by TAC members from local branches linked to each facility assessed:

Is there enough room in the waiting area?

Are you seen within 30 minutes of arriving at the facility?

Are the windows open?

Are there posters telling you to cover your mouth when coughing or sneezing?

Are people in the facility waiting area asked if they have TB symptoms?

Are people who are coughing separated from those who are not?

Are people who cough a lot or who may have TB given tissues or TB masks?

145 facilities were ranked “RED”, 56 facilities were ranked “ORANGE”, and only 2 facilities were ranked “GREEN”. 4 facilities were unable to be ranked due to incomplete data.

Facilities performed especially poorly in the length of waiting times, where over 90% of facilities (190 out of 207) failed to see people within 30 minutes of arriving, pointing to widespread human resource shortages across the clinics surveyed.

57% of facilities (119 out of 207) did not screen people for TB symptoms who were waiting to be seen and 56% of facilities (115 out of 207) did not offer tissues or TB masks to those coughing. It is unknown if this is due to a lack of resources, time, or will.

38% of facilities were found to be too small, and just under 70% of facilities did not (or could not) separate people who were coughing a lot from those who were not, pointing in part to infrastructural challenges that need to be addressed.

TAC commends the 2 clinics that were ranked GREEN – Goso Forest Clinic (EC) and Rhodes Clinic (EC).Our local branches linked to the 2 clinics will award them with certificates and urge them to continue ensuring effective TB infection control. However, if we wish to make progress against TB GREEN ratings should be the norm in the public healthcare system, not the exception.

An Excel sheet with the survey results (including provincial breakdown) can be accessed here.

The problems highlighted in TB infection control through the audit are indicative of the wider crisis within the health system, where overstretched nurses at understaffed clinics lack the capacity and resources to engage effectively in infection control measures.

“While we stress that this is by no means a scientific survey and the results are not generalisable to the rest of the public healthcare system, it does suggest that infection control is a significant problem in many public sector health facilities. As a result, we demand that government carries out a full audit of all public buildings in South Africa, including schools, clinics, hospitals, correctional facilities and home affairs facilities, to assess whether sufficient TB infection control measures are in place,” says Tshabalala.

“If the government is serious about tackling TB, then infection control must be made a priority this year. We do not want to be raising the same issues this time next year – our 2019 audit must see a total turnaround of this situation.”

TAC branch, provincial and national leaders will be meeting with facility management, provincial and national health departments in the coming weeks to discuss the poor outcomes of our TB infection control survey.

NOTE: Not all facilities surveyed in 2017 were repeated in the 2018 audit, and several additional facilities were included this year.

NOTE: Even though TB is the number one reported cause of death in South Africa according to official death notifications, many deaths attributed to TB and other causes are in people with HIV and HIV is thus underrepresented in death notifications. The Thembisa model of HIV in South Africa estimates that there are roughly 150 000 HIV-related deaths per year. A recent Medical Research Council report estimates around 150 000 HIV-related deaths in 2012. These estimates indicate that HIV is still the number one cause of death in South Africa.